2.7.1. Progressive Resistance Exercises plus Manual Therapy (PRE plus MT) Group

Athletes in the PRE plus MT group underwent an amalgamated protocol of resistance exercise and manual therapy [24, 30]. The protocol aimed to strengthen shoulder and scapular muscles, regain range of motion (ROM) of the shoulder quadrant joints, and stretch the shortened muscles. The total protocol duration was of 8 weeks. The strengthening component of the protocol was to be performed 3 times a week, while the ROM exercises were to be done on daily basis for 10 repetitions (reps). Stretching exercise also comprised an important component of the protocol, and 5 repetitions daily withhold of 30 seconds for each repetition were performed by the athletes. The program began with ROM exercises that included shoulder retraction (athletes actively performed shoulder external rotation by keeping elbow in a flexed position), pendulum exercise (athletes performed swinging movement of shoulder joint in a clockwise and counter-clockwise direction for one minute each), an active training of scapula muscles (athletes performed scapular pullbacks while keeping the arms by the side), active-assisted exercises with the cane (athletes performed medial and lateral rotations, flexion, and diagonal elevation by holding a cane with both hands and applied force primarily from the normal side), and posture exercises (athletes were taught to self-correct their abnormal hiking of shoulder while performing active shoulder elevation in front of a mirror). Participants were also educated to perform stretching of the anterior shoulder (athletes while placing their forearms and hand on the wall, stood at an arms distance and then the athlete leaned forward) and posterior shoulder capsule (athletes stood against the wall and while anchoring the affected side scapula brought the affected shoulder into cross-body adduction in such a manner that stretch was felt in the back of the shoulder).

Maitland manual therapy grades (nonthrust) I to IV were used for treatment. A total of 12 MT sessions were administered over a period of 8 weeks [19, 31]. The athlete was in the prone position and the physiotherapist performed the thoracic PA (posteroanterior) glides by keeping the elbow straight and used the pisiform bone to apply the PA glide on the thoracic spinous process. To apply precise mobilization, the physiotherapist hooked the fifth finger of the above hand with the index finger of the bottom hand. Glenohumeral posterior and inferior glide mobilizations were performed by placing the athlete in a supine position with a towel under the scapula. The physiotherapist placed one hand over the humeral head (for posterior glide) and lateral to the acromion (for inferior glide), while the other hand supported the elbow and then a glide in posterior and inferior direction was applied to the humeral head in different elevated positions of below and above 90 degrees. The stability of the shoulder complex was improved by performing strengthening exercises. The duration of phase 1 progressive resistance exercises (PRE) lasted up to two weeks from the inception of the exercises. The exercises were performed with an elastic resistance band by moving in the opposite direction of band fixation (held by the examiner). The resistance exercises comprised of shoulder lateral rotation and medial rotation in a neutral position, scapular retraction (athlete held the resistance band with both hands and then pulled it outwards followed by slow release while keeping the elbow inflexed position), and resisted scapular protraction (bodyweight secured band was pushed towards the ceiling such that the shoulder blades were lifted off the table), while the elbow was kept extended, scapular retraction with chin tuck-in.

The progression pattern of the resistance exercise regime in phase 1 comprised graduating the repetition counts from starting 2 sets of 10 reps to 3 sets of 10 reps. The starting resistance of the elastic resistance band (colour code) was selected on the criteria of repetition maximum, i.e., resistance band that permitted an athlete to complete 8 to12 repetitions per set to the point of fatigue [32]. On every 4^th day of this phase, progression was made by changing the colour of the resistance band (different colours denote varying resistance) [4] [Table 2].

Detailed description of the intervention in the PRE plus MT group.

Abbreviation: PA: posteroanterior; reps: repetitions; PRE: progressive resistance exercise; na: not applicable; Post: posterior; Inf: inferior; NP: neutral position; scap: scapula; retr: retraction.

The duration of phase 2 progressive resistance exercises (PRE) was also 2 weeks. The exercises were performed with the elastic resistance band by moving in the opposite direction (followed by slow descent) of band fixation (held by the examiner), namely, shoulder elevation and flexion up to 90°, shoulder lateral and internal rotation in shoulder abducted and elbow flexed position of 45°-90°, shoulder resisted extension from 45° flexed position, quadruped push-up plus “camel” (athlete was in all four positions and then upper trunk slouching was performed by pushing downwards followed by gradually release), and scapular “T” and “Y” exercise (athlete was in prone lying with the shoulder in abducted and thumbs turned up position, following this athlete raised the arms towards the ceiling and/or raised diagonally up, while contracting scapula together towards spine). At the end of the 4^th week of progression of the resistance, the program consisted of an increase in the repetition counts from the initial 2 sets of 10 repetitions to 3 sets of 10 repetitions. The progression of the band was done every week in this phase (Table 2).

From the 5^th to 8^th week of the therapeutic program, phase 3 progressive resistance exercises (PRE) were performed. With the addition of two new exercises, other exercises remained the same as in phase 2. The exercises comprised of chair press (athlete while in sitting position tried to lift the buttocks off the chair) and “protraction plank” (athlete while in prone plank posture with the thoracic spine in an extended position (slouched) pushed downward through the forearm producing upper trunk spinal flexion position and after that slowly returned to starting position). The progression was made by increasing the repetition count at the end of the 8th week [4] (Table 2).